In this episode of Health Systems Pathways, recorded live at the 8th Global Symposium on Health Systems Research in Nagasaki, Alex Ergo dives into transformative strategies for improving global health systems. This episode explores two key themes: how integrated health data systems are driving universal health coverage (UHC) in India and how the private sector can play a pivotal role in strengthening health systems.

Grace Achungura shares insights from India’s innovative approach to health financing, including the use of interoperable digital infrastructure to harmonise insurance schemes and improve service access. Later, Jessica Jones discusses private sector engagement in global health, focusing on unlocking access to financing and aligning public and private health goals.

Discover practical lessons on collaboration, innovation, and keeping consumers at the heart of health system reform.

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Hi everyone, and welcome to Health Systems Pathways.

This podcast is designed to share insights that inform, inspire, and spark discussions about making health systems easier to navigate in low and middle-income countries.

I'm Alex Ergo, PSI's Director of Health Systems, and I'm thrilled to bring you this special episode recorded live at the Health Systems Research Symposium in Nagasaki.

The theme of the conference this year resonates really well with the work we do at PSI.

Our focus is on building health systems that meet people's needs now and in the future.

That means addressing challenges like integrating health data, understanding consumer needs, advancing self-care, engaging the private sector, and tackling the complex links between climate and health.

In this episode, we'll dive into two of these critical areas.

First, we'll explore how integrated health data systems are helping improve health financing and advance universal health coverage in India.

Then we'll discuss how better collaboration between the public and private sectors can strengthen health systems and improve outcomes for everyone.

These are real world strategies that show how health systems can become more resilient, equitable and responsive.

So, let's get straight into the conversations.

I'm now with Grace Achungura and she will talk about a publication that she just presented about at a recent session at the Health Systems Research Symposium in Nagasaki.

Hi Alex, nice to meet you.

I'm Grace Achungura.

So, I and a couple of colleagues, we did an article on Objectives Oriented Health Systems Research.

It's a supplement that brings together experiences from about 12 countries.

So, India is one of those.

For the Indian case study, we are looking at the role that integrated digital infrastructure can play in furthering UHC.

Objectives and goals and how that has played out in India.

Would you mind to clarify what you mean by objective oriented health system reform?

Because this was the focus of the session, but not everyone may be familiar with this term.

So can you very briefly explain what that means?

Objective oriented health system reform is really trying to get policymakers to think about the ends versus the means.

When determining the direction for policy.

So usually what happens is that um, When a policy window opens for reform, We tend to run to the solution.

Oh, we need health insurance.

Oh, we need performance based financing.

Oh, we need to, to DRGs for instance, Diagnosis Related Groups, Without necessarily thinking about, What is the problem?

What?

Where do we want to go in terms of the objectives of the reform?

And then once you have clarified what your current situation is, where you want to go, then coming back to the drawing board and saying, what are the best tools to fit this solution?

And as the Indian case study will show, it may not necessarily be the usual suspect.

That is the best tool in that situation.

It might be something that is further out of your field that actually provides you a solution to addressing the challenge that is at hand.

Yeah, that's a great point.

I think far too often we come already with a solution to the table, even before we understand what the real problem is.

Now could you just tell us a few words about the article that you presented and that you co-wrote about basically trying to address some fragmentation in the, the data systems in India and how that interoperability has basically helped advance the health financing reforms.

Can you say a few words about, about that?

So, as you know, in 2018, the government of India introduced a public reform on health insurance.

So they moved from RSBY.

Which was the erstwhile scheme for the poor and the vulnerable to the Prime Minister's scheme, PMJ, covering about 5 million households.

And so, as part of that reform, the government working together across different ministries, including ICT, Ministry of Health, the National Planning Think Tank, also bringing on board the state governments and some of their experiences, came up with an integrated information system that learned a lot from the previous experience with RSBY where yes, they had fragmented systems that were largely managed by the states and the insurance companies, but they picked up lessons from that on how to do things better this time around.

They adopted also one of the state scheme's ICT systems that was doing a bit better than the others, as well as also piggybacking on some of the broader government reforms, particularly around interoperability between the beneficiary management systems, the claims management systems, the grievance, reduced systems, building interoperability between those to enable them have one system that not only handles the beneficiary management, but also handles the selective contracting for providers, as well as managing the claims and fraud.

With that system, this was then rolled out to the states and union territories that were involved in PMJ.

That has done a lot, has had important dividends in terms of a UHC standpoint, it has helped in merging the pools together in some states.

So in some states where they were unable to match the pools, they've at least used that system as a basis for harmonizing, um, some of the schemes in terms of for instance, reducing overlaps between different schemes, in terms of the population groups, but also gaps in service coverage to ensure that at least they have similar benefit packages.

A state like Hassan is an example.

In others they've used it to partially merge schemes and in others still they've used it to fully integrate schemes into one.

So, that way now you've you're able to have one populace all having the same benefits across the board that is equitable.

At a national level.

It has also enabled them to ensure portability of benefits across states.

So there are some states, of course, that are economically less advantaged than others.

And so when it comes to service coverage, they may be limited, particularly for high cost tertiary and care, super specialty care.

So what happens is that with the portability that is built within the system, a patient from a disadvantaged state can go and seek care in a different state, which, of course, has more resources and the hospital in the advantaged state is reimbursed seamlessly because they have one transaction management system.

Also, it has helped improve operational efficiency.

We see much faster claims processing much faster beneficiary identification.

It has reduced inclusion and exclusion errors.

It has also helped a lot with the selective contracting, made it a little bit more transparent.

So, with RSBY, you had more of the private sector coming on, but this time around you're having a little bit more parity um, moreover, with the public also, I think having more of a share than the private.

So there are some lessons to learn that really you don't have to always run with the health financing tool.

I think sometimes the solution might lie outside of the health financing subsystems.

So to speak in this case, it's an information system that is usually the purview of the digital health expert.

But if the health financing or health economists come up with the digital specialist in their country piggybacking on broader government reform.

I think the health information system is a good entry point for strengthening the system, cementing not only the information system but the health financing landscape to enable us to achieve UHC goals.

Well, that's an excellent example of basically trying to harmonize and trying to bring together the different pools in some way and, and improve financial protection, but also improve efficiency in a big way.

Do you already have any numbers that show the efficiency gains that have been realized by this experience.

So previously, for instance, pre-authorization would sometimes take days with RSBY, but here you can see on average, most of the states are just under the turnaround time that is the target.

So what we have is 5.

8 hours on average pan India within 5.

8 hours.

Most states have preauthorized a patient to receive care.

Well, the target is six hours and that's even better than what we have with CMS and Medicaid in the US.

So you can see that already in terms of operational efficiency, there are some dividends.

When it comes to portability, you can see at least from around 2018, Almost 2 to 4 percent of all cases in India are portability cases.

And I can tell you that this is a really, really big advantage, especially for cases that require transplantation, that require cardiac surgery.

Some of these states do not have the capacity to do so.

So when you can see patients reporting back and saying, I was able to have this transplant for free, and yet the state does not offer that.

That's a big thing, Alex.

So that's a major achievement.

And I imagine that also leads to great satisfaction both among the patients or among the enrolled population and among the providers, right?

Yes, it is.

The providers do appreciate it.

Most of the providers that we've interviewed for other research purposes, have appreciated the scheme and the changes that have happened.

Of course, there are growing pains that can happen with any new system, but overall, I think there's been much better satisfaction given these changes.

Well, thank you so much for sharing that.

It was a great session and really a great example that you just shared with us.

So thank you so much and hope you enjoy the rest of the conference.

I'm now with Jessica Jones.

Jessica is Technical Advisor on Frontier Health Markets Engage.

You had a session already this morning.

Would you mind just sharing your first impressions?

First impressions of the session this morning, which was on, uh, changing incentives for engaging the private sector in global health.

I'm really encouraged by how many people were interested in coming to a very early first day satellite session on the private sector.

For those of us who've been working in the private sector a long time, we know that there's always been a role for the private sector in global public health, but I do feel like the dialogue on the role of the private sector in global public health in health systems conversation is changing and that there's increasing interest in and energy around conversations about engaging the private sector as well as a recognition of the really important role of the private sector not only could play but already does play in global public health.

Great, and if I'm not mistaken, in your first session, you talked about private sectors access to financing so that they can invest in their business.

What do you think could be incentives for private providers to make sure that these investments in their business also benefit the wider system, so are better aligned with the public health goals.

One of the topics that we talked about quite a bit in the session this morning was whether or not we even need to go for that shared alignment between the private sector and the public sector in terms of bringing the private sector into public health goals.

The private sector has already a mandate and incentives around providing a public health a service that individuals or governments will pay for and differentiating themselves based on quality or access or range of services.

And so by providing access to affordable finance, we are unlocking the potential of the private sector to grow into a role where they can meet those needs that are already there.

We've really focused on FHM Engage on being that facilitator of access to finance, of working with these private sector businesses to understand what their needs are to access available financing, understand what supportive services or shared technology transfer that they might need to be able to be eligible to access financing, as well as working with financers to help demystify the health sector and make that worth their while.

We have not spent a lot of time on monitoring what happens to the funding afterwards.

Um, we are of course paying attention, but we really hope by aligning those upfront incentives um, between the private health providers and the financers that we're already working towards shared public health goals.

And that's great.

And what do you feel about the stewardship of private providers?

What do you think should be done more of to improve it and to make sure that private and public sector are better integrated in the longer term?

So, two immediate reactions to that.

I think one, of course, it entirely depends on the country.

Models of stewardship and private sector governance are very different across different country contexts and it's important to go in with an understanding of what's already in place.

And what has been tried to engage the private sector and where that's working, and if it hasn't worked, why it hasn't worked.

The other thing I would push back on a little bit is we had a conversation as part of our session this morning about that governance and stewardship of the private sector shouldn't be a separate issue.

It's not a separate endeavor, but rather that we have been doing governance and stewardship all along of the public sector and it's more about involving the private sector as part of the overall health system rather than treating it as a separate entity to be governed.

And so it's really that holistic look at the health system overall and making sure that the public and private sectors are effectively stewarded by the government.

Just a follow up question on that.

Do you feel that they are already engaged in those discussions or do you think that more could be done?

And if so, how?

Again, it entirely depends on the country.

I would say in more cases than not, um, there is definitely room for improvement.

And one of the biggest takeaways that I have from this is that there has been a lot of thinking in global public health about how to engage the private sector in the sense of bring the private sector to the public sector and not a whole lot of thinking about what the private sector actually needs to want to be engaged in the first place.

And so there's been a lot of efforts in technical working groups where there's a private sector seat and sometimes they come and sometimes they don't.

But a lot less in communicating that shared value proposition of what is in it for the private sector and why would it make a business case for them to be stewarded in the first place.

And so more of that thinking from the private sector perspective about how we can make this a shared value conversation and worth everybody's while is I think what we could do a lot better at.

Well, a big thank you to Grace and Jessica for sharing their insights.

I hope these two conversations gave you a flavor of what we're learning here in Nagasaki.

They both touched on how health systems are being transformed from using integrated data systems to improve health financing, to engaging private sector actors as equal partners in health system governance, and they both also underscore the importance of collaboration of innovation and keeping the consumer at the center of it all.

So, thank you for tuning into Health Systems Pathways.

I hope you enjoyed this episode.

If you did, please subscribe or follow us wherever you get your podcasts so you don't miss the next episodes.

Until next time, I'm Alex Ergo, so let's keep working together to build stronger health systems that work for people.